International
Organizations
AUSTRALIA
Palliative
Care Australia
NORTH AMERICA
USA
American Academy of
Hospice and Palliative Medicine
Hospice and Palliative Nurse Association's
Statement in Response to Supreme Court Ruling on Physician-Assisted Suicide
The Hospice Nurses Association, together
with the National Hospice Organization and the Hospice Association of America,
the country's leading advocates for terminally ill individuals and their
families, applaud the Supreme Court's attention to the physician-assisted
suicide issue. We express concerns, however, that the decision may raise more
questions than it answers.
The question shouldn’t
be whether the state has an interest in allowing a person to ask a doctor to
help them commit suicide, but whether the state has an interest in helping
citizens live out their last days as comfortably and with as much dignity as
possible.
Many terminally ill patients turn to
physician-assisted suicide not because they cannot be cured, but because they
cannot bear the thought of physical pain and depression they fear will accompany
a terminal prognosis. When terminally ill patients are given proper medical,
nursing and supportive care, the desire for assistance with suicide decreases.
Hospice is a comprehensive, medically directed, team-oriented program of care
that emphasizes pain control and symptom management rather than curative
treatment. It is a philosophy of care that accepts death as a natural part of
life, and addresses the psychological and spiritual needs of the patient and
family.
Hospice Nurses Association Position on
Physician-Assisted Suicide Adopted May, 1994 The Hospice Nurse Association, the
organization that speaks nationally for hospice nurses committed to
compassionate care of the terminally ill, Having witnessed first hand the
phenomena of palliation or relief of pain and suffering and the maintenance of
patient/family defined quality of life of dying patients and their families in
hospice care, · Opposes the legalization of euthanasia and assisted suicide We
reaffirm the hospice concept of care that neither hastens nor postpones the
onset of death· In addition, we support all activity toward open discussion,
public or private, about these or any other issues that concern hospice patients
and families· Finally, we support all public policy changes that would ensure
access to hospice care irrespective of patient age or diagnosis and
patient/family socioeconomic status.
Statement from the Academy
of Psychosomatic Medicine
Academy of Psychosomatic Medicine
The Organization for Consultation-Liaison Psychiatry
POSITION STATEMENT: Psychiatric Aspects of
Excellent End-of-Life Care
The Academy of Psychosomatic Medicine (A.P.M.)
is the organization of Consultation-Liaison (C-L) Psychiatry. Its international
membership includes many of the leading clinicians and researchers in the field
of C-L Psychiatry, a discipline which focuses on the psychiatric care of the
medically ill. This clinical focus includes the psychiatric problems of
catastrophically ill and dying patients. Prepared by the A.P.M.'s Ad Hoc
Committee on End-of-Life Care, this Position Statement has been approved by the
A.P.M. Executive Council in the method described in the constitution and bylaws
of the A.P.M. This document is the A.P.M.'s Position Statement regarding
psychiatric aspects of care provided to patients nearing the end of life.
1. Psychiatric morbidity at the end of life
is significant and causes substantial, potentially remediable suffering to dying
patients and their families. Further, we believe that quality care for the
psychiatric complications of terminal illness is and should be an integral
component of excellent, comprehensive end-of-life care.
2. The most basic challenge at the end of
life which stresses patients and families is loss, which is related to both the
disabilities of the illness with their threats to self-esteem, and the patient's
death, which ruptures the direct relationship with the family. Psychiatric
problems and issues commonly seen at the end of life include anxiety symptoms
and anxiety disorders, depressive symptoms and depressive disorders, delirium
and other cognitive disorders, suicidal ideation, consequences of low perceived
family and other social support, personality disorders or personality traits
that cause problems in the setting of extreme stress, questions of capacity to
make informed decisions, grief and bereavement, and general and health-related
quality of life. Spiritual and religious issues, including both personal faith
and relationship to a community of believers, are important for most people.
Good end-of-life care requires explicit attention to these matters.
3. Studies show that psychiatric morbidity
in the setting of terminal illness is exceptionally high. The prevalence of
delirium in terminal cancer and AIDS patients ranges from 30-85%, and the
prevalence of clinically significant depression ranges from 20-50%. The
prevalence of depression among terminally ill patients with a desire for death
is eight times higher than in those without a significant de sire for death.
Depression is the strongest determinant of suicidal ideation and desire for
death in those with serious or terminal illness.
4. Psychiatric complications at the end of
life are treatable, but often go unrecognized and untreated. Several factors or
barriers contribute to the underrecognition and undertreatment of psychiatric
problems at the end of life. These include:
Difficulty in diagnosing psychiatric
disorders (e.g., anxiety, delirium, depression) in the setting of significant
physical illness, owing to the overlap in the symptoms caused by the psychiatric
disorder and the comorbid physical problems.
Beliefs held by many patients, family
members, physicians, and hospice and palliative care providers whereby
psychiatric symptoms, especially depression, are viewed as normal parts of the
dying process.
The fact that many patients and physicians
do not understand that patients who suffer from mental disorders at the end of
life can respond to treatment. This therapeutic nihilism prevents the search for
treatable mental disorders at the end of life.
The presence of structural barriers to
coordinated care of dying patients. Psychiatrists may not be readily available
to care for terminally ill patients and consult with physicians providing
end-of-life care for a variety of reasons. Among these are limited geographic
access (most C-L psychiatrists are affiliated with academic medical centers in
urban areas), psychiatrists who feel inadequately prepared to assess and treat
dying patients, healthcare insurance carve-outs (which may limit or exclude
access to and coverage for psychiatric care), and logistical obstacles to formal
addition of a psychiatrist to a hospice care team.
The stigma experienced by patients and
families due to psychiatric evaluations or the assignment of a psychiatric
diagnosis. Physicians and other caregivers may share this feeling.
The occurrence of countertransference of
hopelessness on the part of families and healthcare providers that may
discourage seeking assessment of suffering from psychiatric causes in dying
patients and weaken the commitment to helping maintain morale at the end of
life.
The fact that treatment based on formal
diagnosis (as opposed to symptomatic treatment) is not sufficiently emphasized
in palliative care.
5. We believe that the current enthusiasm
for legalized assisted suicide and euthanasia at least partly reflects public
concern that suffering (including suffering due to psychiatric causes) and
distress at the end of life may elude or exceed our best current treatment
efforts, making death seem preferable. Appropriately, aggressive treatment for
psychiatric complications of terminal illness is the best way to address this
fear and should reduce requests for assisted suicide and euthanasia.
6. We maintain that laws and regulations
must allow physicians to provide appropriately aggressive care for psychiatric
complications of terminal illness and must provide protection for qualified
physicians who provide this care. For example, excellent treatment of depression
at the end of life often requires the use of psychostimulants, most of which are
Schedule II controlled substances. Appropriate use of these agents to control
depression at the end of life should be viewed as analogous to the use of opiate
analgesics to treat pain in this setting. Similarly, appropriate treatment of
agitated and delirious patients who are dying may require sufficient sedation to
relieve the suffering of the patient and family. When clinically indicated and
acceptable to the patient or surrogate, such sedation is the standard of care
and should be employed even if it hastens death. Such treatment is ethically
sound and is not an act of assisted suicide or euthanasia.
7. In response to the above, the A.P.M.
believes that remedial efforts must be encouraged. These include:
Education about the prevalence and morbidity
of psychiatric complications of terminal illness. Target audiences should
include the general public, students and trainees in all healthcare professions,
and healthcare providers in hospice and palliative care, primary care, and
medical specialties (including psychiatry).
Education and other efforts to reduce or
remove barriers to excellent psychiatric end-of-life care, as outlined in
Section 4 above.
Education and advocacy efforts to insure
that legal or regulatory barriers do not hinder or prevent excellent psychiatric
care at the end of life.
Clinical (and, where appropriate, basic
science) research into psychiatric complications of terminal illness, their
effects on suffering and quality of life in dying patients and their families;
interactions with other comobid conditions such as pain, fatigue, shortness of
breath, anorexia and nausea; and reliably effective treatment strategies used at
the end of life. Collaboration with governmental funding agencies and private
foundations should be encouraged to develop research in these areas. Particular
attention should be paid to training young investigators in research related to
the psychiatric complications of terminal illness.
National Hospice
Organization
RESOLUTION ON ASSISTED SUICIDE
WHEREAS, The National Hospice Organization
is considered the voice of the nation's hospice community; and,
WHEREAS, The National Hospice Organization
is often requested to provide comment to the Congress, the Administration, the
Courts, the
media and the general public; and,
WHEREAS, The National Hospice Organization
is on record as supporting a patient's right to choose palliative care and a
patient's right to refuse
unwanted medical intervention including the provision of artificially supplied
hydration and nutrition; and,
WHEREAS, There has been increased public
attention and focus on the issue of voluntary euthanasia and assisted suicide;
and,
WHEREAS, The proponents of change in the
legal status of these practices often paint a stark picture in which a patient's
choice is between
painful existence devoid of value on the one hand and voluntary euthanasia or
assisted suicide on the other; and,
WHEREAS, We believe hospice care is a better
choice than voluntary euthanasia and assisted suicide; therefore,
RESOLVED, That the National Hospice
Organization reaffirms its commitment to the value of the end of life and to the
philosophy that hospice
care neither hastens nor postpones death.
RESOLVED, That the National Hospice
Organization does not support the legalization of voluntary euthanasia or
assisted suicide in the care of
the terminally ill.
RESOLVED, That the National Hospice
Organization supports improved access to hospice care for terminally ill
patients and their families,
including those who have expressed a desire for assistance with suicide.
Adopted by the Membership November, 1996
1901 N. Moore St., Ste. 901 Arlington, VA
22209 (703) 243-5900 (703) 525-5762 fax
Copyright 1997, National Hospice
Organization, Arlington, VA
CANADA
Canadian
Palliative Care Association
The Canadian Palliative Care Association is
opposed to legalized euthanasia and assisted suicide
We call instead for palliative care services
to be accessible to all dying persons in Canada, their families and caregivers.
Comprehensive palliative care addresses the pain and suffering of persons
living with life threatening illness and their families. In Canada, people have
the right at any time to refuse or stop treatment.
1997
Great Britain
National Council
for Hospice and Specialist Palliative Care Services ETHICAL DECISION-MAKING IN
PALLIATIVE CARE: Cardiopulmonary Resuscitation (CPR) for people who are
terminally ill
This paper has been prepared by a Joint
Working party between the National Council for Hospice and Specialist
Palliative, Care Services and the Ethics Committee of the Association for
Palliative Medicine of Great Britain and Ireland.
Experience has shown that, when drawing up
and implementing CPR policies, it is necessary to give particular consideration
to the needs of terminally ill patients. It should be noted that good practice
suggests that decisions regarding CPR should involve a multiprofessional team,
the patient, and relatives and carers, but that the senior doctor has ultimate
responsibility for the decision.
1. There is evidence, (1, 2, 3) to suggest
that, for terminally ill patients, the harms of CPR are likely far to outweigh
the possible benefits. Evidence indicates that, almost invariably, CPR either
fails to re-establish cardiopulmonary function, or succeeds only to result in
further cardiopulmonary arrest with no intervening hospital discharge.
(a) CPR is inappropriate (4) if (i) there is
virtually no chance of CPR re-establishing cardiopulmonary function; or (ii)
successful resuscitation would probably result in a quality of life unacceptable
to the patient (recognising that the focal point of any such decision would be
the views of that patient); or (iii) it is contrary to the competent patient's
expressed wishes.
(b) CPR may be appropriate if 5. (i) there
is a reasonable chance of CPR re-establishing cardiopulmonary function; and (ii)
successful resuscitation would probably result in a quality of life acceptable
to the patient (recognizing that the focal point of any such decision would be
the views of that patient); and (iii) it is the competent patient's expressed
wish. (See Point 5)
2. There is no ethical obligation to discuss
CPR with the majority of palliative care patients, for whom such treatment,
following assessment, is judged to be futile (1-8). In the context of open and
honest discussion, the raising of such issues may be redundant and potentially
distressing.
3. If the likely outcome of a CPR
intervention is uncertain, anticipatory decisions either to implement or
withhold CPR should be sensitively explored with the patient. Both the
likelihood of success and the resulting quality of life will be appropriate
issues for discussion. Review of any such decision may be appropriate with
change in the patients clinical situation.
4. Should a patient be likely to benefit
from CPR and would wish for it, the extent of CPR facilities and expertise
available in any admitting unit ought to be discussed with the patient, ideally
prior to admission. Limited availability of such facilities in specialist
palliative care units need not undermine appropriateness of admission in early
disease as patients may accept such admission on the understanding that initial
resuscitative measures will be instituted and transfer to a unit equipped to
undertake CPR will be arranged in the event of a cardiac arrest actually
occurring.
5 Consideration should be given to CPR
policy early in the involvement of the clinical team. In the absence of an
anticipatory decision or a valid advance refusal, at the time of
cardiorespiratory arrest, the patient is by definition incompetent to make a
decision regarding CPR and therefore it is the doctor's legal responsibility to
act in the patients best interests.
Notes (I) "Terminally ill people are
those with active and progressive disease for which curative treatment is not
possible or not appropriate and from which death can reasonably be expected
within twelve months" (from Care of People with Terminal Illness, NAHAT,
1991; EL (95) 22, NHS Executive 4. 23 February 1995; and Specialist Palliative
Care: A Statement of Definitions, NCHSPCS, 1995).
(II) Decisions concerning CPR policy for
individual patients should be clearly recorded and communicated to all relevant
5. staff, including deputising or GP cooperative services.
(III) It would be helpful if ambulance
service providers could be made aware of the policy relating to individual
patients who would not benefit from, or wish for, CPR. Local mechanisms for the
communication of anticipatory decisions to paramedical staff in relation to
individual patients in the domiciliary setting would also be helpful.
References 1. Dautzenberg RL.J, Broekman
T.C.J, Hooyer C, Schonwetter R.S, Duursma S.A. Review: Patient-related
predictors of cardiopulmonary resuscitation of hospitalised patients, Age and
Aging 1993: 22. 464-475. 2, Bedell S.E, Delbanco T.L, Cook EY, Epstein F.H.
Survival after cardiopulmonary resucitation in the hospital, N Engl J Med
1983:309:569-575. 4. Ebell M.H. Pre-arrest predictors of survival following
in-hospital cardiopulmonary resuscitation; comparison of two predictive
instruments, Resuscitation 1994: 28: 21-25. 5. British Medical Association and
Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation.
Joint statement in association with the Resuscitation Council (M, BMA House,
London, March 1993. Sommerville A. Cessation of treatment, non-resuscitation,
aiding suicide and euthanasia. In: Fisher F. Medical Ethics Today: Its practice
and philosophy, London BMJ Publishing Group, 1993: 173. 6. Murphy D.J, Burrows
D, Santilli S et al. The influence of the probability of survival on patients
preferences regarding cardiopulmonary resuscitation, N Engl J Med
1994:330:545-549. 7. Miller D.L, Gorbien MA Simbartl LA, Jahnigen D.W. Factors
influencing physicians in recommending in-hospital cardiopulmonary
resuscitation, Arch Intern Med 1993: 153: 1999-2003. 8. George A-L, Folk BY,
Crecelius PL, Campbell W.B. Pre-arrest morbidity and other correlates of
survival after in-hospital cardiopulmonary arrest, Am J Med 1989: 87: 28-34.
JOINT WORKING PARTY BETWEEN THE NATIONAL
COUNCIL FOR HOSPICE AND SPECIALIST PALLIATIVE CARE SERVICES AND THE ETHICS
COMMITTEE OF THE ASSOCIATION FOR PALLIATIVE MEDICINE OF GREAT BRITAIN AND
IRELAND
Mrs B Biswas, Matron, LOROS, Leicestershire
Hospice, Leicester Dr K Dunphy, Macmillan Consultant in Palliative Medicine,
Macmillan Runcie Day Hospice, St Albans. Dr J Ellershaw, Medical Director, Marie
Curie Centre, Liverpool Dr M Minton, Consultant in Palliative Medicine, Sir
Michael Sobell House Palliative Care Unit, The Oxford Radcliffe Hospital. Mr D
Oliviere, Macmillan Lecturer in Social Work and Palliative Care, School of
Social Work and Health Sciences, Middlesex University, Enfield Mr D Praill,
Chief Executive, Help the Hospices, London Dr F Randall, Consultant in
Palliative Medicine, Macmillan Unit, Christchurch Hospital, Dorset Dr G Rathbone,
Consultant in Palliative Medicine, LORDS, Leicestershire Hospice, Leicester Dr T
Tate,- Consultant in Palliative Medicine, The Margaret Centre, Whipps Cross
Hospital; Consultant in Palliative Medicine, St BartholomeVs Hospital, London
National Council for Hospice and Specialist
Palliative Care Services Heron House, 322 High Holborn London WCIV 7PW Tel:
0171-269 4550 Fax 0171-269 4548 A Company limited by guarantee number 2644430
Registered Charity No 100567 1
National Council for Hospice and Specialist Palliative Care Services
VOLUNTARY EUTHANASIA: The Council's View
Adopted by Council on 17th July 1997
Introduction
The National Council for Hospice and
Specialist Palliative Care Services is the representative and coordinating
multiprofessional body for those providing hospice and specialist palliative
care services in England, Wales and Northern Ireland.
This document represents the view of Council
on voluntary euthanasia which may be defined as direct killing of patients at
their own request to prevent further suffering.
Hospice and specialist palliative care
services aim to promote comprehensive care for those with progressive advanced
disease and a short life expectancy in order to maximise the quality of life
remaining, enabling patients 'to live until they die' and includes psycho-social
care as well as adequate pain and symptom management. Such provision also
recognises and aims to meet the needs of relatives and careers through
professional advice and support for the close family and friends of the patient.
Council endorses the conclusions of the
House of Lords Select Committee on Medical Ethics (1994).(1) This document
elaborates upon some of those conclusions, reproduced here in bold.
1. The principles of palliative care affirm
life whilst regarding death as a natural process to be viewed neither with fear
nor a sense of failure. Death may be impossible to postpone but should not be
hastened. Respect for the dignity of the individual is important, and regarded
by many as paramount. Such respect is not manifest in the act of killing the
patient which would merely serve to confirm the individual's falsely devalued
sense of self-worth.
"We recommend that there should
be no change in the law to permit euthanasia (para. 237)". (para. 278).
2. Those arguing for the
legalisation of euthanasia point to a feeling of powerlessness that many
patients experience in their relationships with their doctors. Yet the legal
right of patients to reject treatment is well established. Patients should be
reassured, and left in no doubt that they cannot be subjected to life-prolonging
procedures against their will.
Some people fear that whilst they
remain reasonably well they will be able to adequately express their wishes
regarding treatment, but that, with increasing debility, they may lose this
power and with it the ability to exercise control over their continuing medical
care. Palliative care involves a partnership between patient and professional in
which the professional seeks to establish the evolving care wishes of the
patient within an emotional environment of honesty, openness and trust. With
care such as this the patient should have no doubt that, should they become
unable to express their wishes, their further medical management will continue
to reflect their previously expressed sentiments. Written advance directives are
a more formalised way of achieving the same result, despite their lack of
statutory basis. However, case law in this country leaves little doubt that an
informed, competent, applicable and voluntary refusal of treatment is legally
binding on the doctor. Council welcomes this.
"We strongly endorse the right
of the competent patient to refuse consent to any medical treatment (para.
234)".(para 279)
"We commend the development of
advance directives, but conclude that legislation for advance directives
generally is unnecessary (paras. 263, 264)". (para 296)
3. Some doctors and carers
experience difficulty in what they perceive as a choice between leaving the
patient at a safe dose of analgesic but in discomfort on the one hand and giving
an 'overdose’ deliberately precipitating death on the other. The choice is
largely an illusion. The occasional need for high doses of analgesics and other
drugs in the final stages of life can cause anguish among doctors and
care-givers alike and lead to the perennial misinterpretation by the media and
the public of this as euthanasia by stealth. The dosage required by one patient
may be hundreds of times greater than that required by another, affording
comfort to that individual without compromising the level of consciousness or
lucidity.2 Even if, however, 1.Report of the Select Committee on Medical Ethics
(1993-94)HL 21-1 2~(a) Plasma Concentrations and Renal Clearance of Morphine;
Morphine - 3 Glucuronide and Morphine 6 Glucuronide in Cancer Patients Receiving
Morphine. Clin Phamacokinet, Somogyi AA et al, 1993; 24(5); 413-20 (b) Analgesic
Use in Home Hospice Cancer Patients. McCormack A et al. J Fam Pract 1992; 34(2);
160-4 c Control of Severe Pain in Children with Terminal Malignancy. J Pediatr,
Collins JT et al, 1995; 126(4): 653-7 there is some real risk of shortening
life, the reasonable and responsible doctor will not shirk from adequate symptom
control. This is legally sound and ethically defensible through the principle of
double effect. The principle asserts that if a good effect is achievable only at
the risk of producing a bad effect, this is permissible provided the intention
is solely to produce the good effect. Doctors already have all the latitude they
require in legal terms to ensure that patients do not die in pain.
"Double effect is not in our
view a reason for withholding treatment that would give relief, as long as the
doctor acts in accordance with responsible medical practice with the objective
of relieving pain or distress, and without the intention to kill (para.
242)".(para. 282)
4. Council believes that the
widespread and equitable availability of specialist and other palliative care
services will do much to minimise rational and persistent requests for
euthanasia. The wider availability of palliative care services would be an
expression of society's humanitarian concern for people who are dependent,
disabled or dying.
"We strongly commend the
development and growth of palliative care services in hospices, in hospitals and
in the community (para. 241)" (para. 281)
However, universal availability of
excellent palliative care services will not and can never eliminate all such
rational and persistent requests for euthanasia. For those few who would make
persistent and rational requests for euthanasia despite the availability of high
quality palliative care, the provision of such care may seem to have no
relevance. For them, the debate has moved beyond the practicalities and
limitations of any medical or psychosocial management.
In these circumstances the law
should reflect the respective moral weights given to the claims of the person
who wishes to die on the one hand and the wider interests of society on the
other. Council believes that to legalise euthanasia will risk undermining the
freedoms of the majority of society in an attempt to promote the autonomy of the
small minority of patients who might retain an interest in ending their lives in
this way. This risk to society arises from the potential for abuse of legalised
euthanasia by, for example, increasing the pressure (real or imagined) that
legalised euthanasia might place on vulnerable people and by the denial of value
of elderly, chronically infirm, and dependent people. Council believes these
risks to be real, Even if we could be convinced otherwise, ethical problems in
the direct killing of patients would persist. We acknowledge that maintaining a
legal prohibition on the practice of euthanasia exacts a high price on some
individuals who may feel that their autonomy has been unacceptably com-promised.
In these circumstances, health professionals should acknowledge and respect the
values and wishes of such patients uncritically, aiming to enhance personal
autonomy and sense of self-worth, and instituting no treatment or aspect of care
without the active involvement of competent patients and with their duly
informed consent. The arguments advanced indicate that respect for individual
autonomy cannot be an absolute value. Regard for the dignity of the individual
cannot require health professionals to respect autonomy to the extent of honoring
requests for euthanasia, nor can it ignore the potential adverse
effect on health professionals or society in general.
Council reaffirms that the intention
of good palliative care for dying patients is to relieve their physical,
emotional, social and spiritual suffering in the context of respect for their
individuality, and without intent to shorten life.
Council believes there is no place
for the direct killing of patients at their own request.
"Rejection of euthanasia as an
option for the individual entails a compelling social responsibility to care
adequately for those who are elderly, dying or disabled (para. 276)". (para.
287)
Useful Reading:
Report of the Select Committee on
Medical Ethics, Volume 1 - Report, House of Lords (1993-94) (HL Paper 214)
Advance Statements about Medical neatment -available from the British Medical
Association, Tavistock Square, London, WC1H 9JP at 6.95 pounds. Advance
Statements about Future Medical Treatment : A Guide for Patients - available
from the Patients Association, 8 Guilford Street, London, WC1N 1DT at 3 pounds.
MEMBERSHIP OF COUNCIL'S WORKING
PARTY ON ETHICS:
Dr Teresa Tate, (Chairman),
Consultant in Palliative Medicine, The Margaret Centre, Whipps Cross Hospital
Consultant in Palliative Medicine, St Bartholomew's Hospital, London Mrs Bronwen
Biswas, Matron, LOROS, Leicestershire Hospice, Ioeicester Mrs Jo Bray,
Occupational Therapists Specialist Section HOPE Mr Michael Connolly, Macmillan
Palliative Care Nurse, Wythenshawe Hospital, Manchester Dr Kilian Dunphy,
Macmillan Consultant in Palliative Medicine, West Herts Community Health NHS
Trust, St Albans. Dr Bobbie Farsides, Centre of Medical Law and Ethics, King's
College London (co-opted) Dr Rob George, Senior Lecturer Palliative Medicine,
Palliative Care Centre, U.C.L. Medical School Ms Pam McClinton, Clinical
Development Adviser, South Bedfordshire Community Healthcare Trust Mr David
Oliviere, Macmillan Lecturer in Social Work and Palliative Care, School of
Social Work and Health Sciences, Middlesex University, Enfield Mr David Praill,
Chief Executive, Help the Hospices, London THE NATIONAL COUNCIL Honorary
President: Honorary Vice Presidents; Chairman Vice-Chairmen: Honorary Treasurer:
National Cancer Charities Macmillan Cancer Relief Help the Hospices Marie Curie
Cancer Care Sue Ryder Foundation NHS Hospices and Teams! Representative
Professional Organisations Association for Hospice Management Association of
Hospice and Specialist Palliative Care Social Workers Association for Palliative
Medicine of Great Britain and Ireland RCN Nurses Managing Hospices/Specialist
Palliative Care Services RCN Palliative Nursing Forum Forum of Chairmen of
Independent Hospices Dame Cicely Saunders OM DBE FRCP Professor Eric Wilkes OBE
Sir Robert Evans CBE FEng Norman Blacker Dr Derek Doyle OBE Nicholas Young John
Overton FCA Regional Representatives Sixteen regional representatives, elected
by hospices and home cire teams, both voluntary and NHS, in the health regions
in England, Wales and Northern Ireland. Observers Scottish Partnership Agency
for Palliative and Cancer Care Department of Health ACT (Association for
Children with life-threatening or Terminal conditions and their families)
Executive Director Mrs Jean Gaffin OBE
